Provider Demographics
NPI:1437783529
Name:TELEMENTAL HEALTH LINK LLC
Entity type:Organization
Organization Name:TELEMENTAL HEALTH LINK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DERIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:208-775-7418
Mailing Address - Street 1:4055 E BLUEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8261
Mailing Address - Country:US
Mailing Address - Phone:208-600-2060
Mailing Address - Fax:208-647-5008
Practice Address - Street 1:4055 E BLUEBERRY ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8261
Practice Address - Country:US
Practice Address - Phone:208-775-7418
Practice Address - Fax:208-647-5008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSYCHIATRIC NURSE PRACTITIONER SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
396453OSMINDOtherCHANGE HEALTHCARE MASTER BILLING ID
NM58322OtherNURSING LICENSE
NM58322OtherNEW MEXICO APRN CNP LICENSE
ID020837Medicaid
13961493OtherCAQH ID
ID64266OtherNURSING LICENSE
LA03962OtherNURSING LICENSE
1529234OtherNCSBN ID
0364158OtherANCC CERTIFICATION NO.
LA363LP0808XOtherTAXONOMIES: NURSE PRACTITIONER PSYCH MENTAL HEALTH
LAP69441OtherUPIN
NM58322OtherNEW MEXICO APRN CNP LICENSE